This study assessed community access, utilization and acceptability of the use of malaria rapid diagnostic tests (RDTs) and respiratory rate timers (RRTs) by CHWs following one year of implementation. Accessibility to CHWs was high, with majority of the households residing within one kilometer of a CHW’s home. Most respondents reported taking 10 minutes to walk to a CHW’s home. Utilization of CHW services for febrile children was high, with more than half of respondents reporting to have taken an under-five to a CHW in the three-month period preceding the survey. About 80% of all respondents reported CHWs services as better after introduction of RDTs, while among respondents that utilized CHWs services in the three months to the survey, nearly all reported services as having improved following introduction of RDTs. Majority of respondents reported that RRTs were useful. Utilization of CHW services was associated with distance of household to the nearest health facility, and distance of household to nearest CHW. Households residing 1-3 km from a health facility were 72% more likely to utilize CHW services compared to households residing within 1 km of a health facility. Households residing within 1-3 km from a CHW were 81% less likely to utilize CHW services compared to those households residing within 1 km of a CHW.
The high accessibility by households to CHWs suggests that the program is meeting its goal of bringing curative services for febrile children as close as possible to their homes. CHW programs have been reported to improve access to prompt treatment for febrile children [34–37].
CHWs were the preferred choice for care for febrile children with drug shops a close second at over 30%. Drug shops remain very popular in spite of available free services for febrile children through CHWs. There is extensive literature from Tanzania [38–41], Kenya [42, 43], Uganda [44, 45] and elsewhere showing the important role that drug shops play as a source of care especially for malaria. Some of the reasons why caregivers did not utilize CHW services were lack of drugs, dislike of CHW services, not being aware of the CHWs services in the community, missing CHW in their homes on a visit, or being closer to a health facility. The program indeed experienced drug stock-outs from time to time, and this appears to have had a significant impact on caregiver choices. In many cases, caregivers continued to bypass CHWs and go elsewhere even when drug stocks had been replenished. CHW programs need to take measures to ensure stock-outs do not occur, or are kept at a minimum. In case it becomes unavoidable, there should be clear and timely information regarding when drugs are expected. Distance to the provider, and perceived skills of the provider were also found to be key drivers of choice of service provider. CHW programs need to ensure that the majority of community members have easy reach to CHWs, especially those in rural and hard to reach areas. A systematic review of access and utilization of health services shows that availability of drugs, distance to health facilities, and perceived quality of care are the key determinants influencing health service utilization .
Geographical factors influenced utilization of CHW’s services. The closer caregivers were to CHWs the more likely they were to use them. This is consistent with the program objectives. However, caregivers who were close (within a kilometer) to a health facility were less likely to utilize CHWs compared to those who resided farther way from a health facility. This finding has policy implications for CHW programs such as this. Since programs are designed to provide access to care for under-served, hard-to-reach communities, CHWs will need to be located carefully, so that only under-served communities are selectively included. In well-served communities where CHWs exist, they could provide services that complement what a nearby facility provide, including health education, health promotion, and referral services. Programs in these areas will also need to take into account the other contextual factors such as buy-in from medicine sellers as proposed by Goodman et al.. Lehmann et al. have made the case that CHWs are neither a panacea, nor cheap option for weak health services. As health services increasingly get strengthened and coverage improves, the roles of CHW will need to be carefully defined and refocused. Equally important is the fact that even when services are available they may not be accessible to the poorest in a community and in turn enhance inequities . CHWs have a role in bringing these services closer to the poorest and excluded segments of communities.
Majority of caregivers that visited a CHW were satisfied with the service they received. Availability of drugs and use of diagnostics in this setting were key drivers of satisfaction. This is consistent with findings reported by Nsabagasani et al. from western Uganda where both CHWs and caregivers agreed that diagnostic equipment at community level would improve diagnosis and attract more caregivers of febrile children.
Caregivers do not want to go where there are no drugs, as they feel they are wasting time and will have to go to the next provider.
Almost all caregivers had no fears about drawing of blood from under-fives by CHWs for the RDT test. Similar results have been reported from Zambia in a study where CHWs used RDTs in home management of childhood fever . An earlier qualitative study from this area reported that some caregivers expressed fear that the blood collected could be used for HIV testing, the procedure could infect children with HIV, and the blood could be used for witchcraft . This study was conducted prior to the introduction of RDTs in the community. It appears that the direct interaction of caregivers with competent CHWs  using the RDTs, and the community engagement that was undertaken prior to the intervention may have changed some of the negative perceptions. Majority of caregivers thought CHW services were better after introduction of RDTs, and nearly 90% of all caregivers interviewed approved of CHWs continued use of RDTs and RRTs.
The overall RDT positivity rate in the intervention study preceding this study was 88% (857/975) . Acceptability of RDTs by caregivers might be different in settings were the positivity rate is much lower. In situations where caregivers of children feel that their children are “ill enough” to warrant prescription of an anti-malarial drug, with or without a positive test result, and where CHWs strictly adhere to RDT test results to guide prescription practices, it is plausible that popularity of tests and CHWs will be lower. The importance of identifying alternative causes of fever will be even more critical in these settings, as well as ensuring that CHWs are equipped to manage conditions such as non-severe pneumonia as has been reported elsewhere [24, 27]. A study from the Solomon Islands, on acceptability of RDTs reports a general distrust by the community of the accuracy of RDTs, resulting in continued presumptive treatment of malaria . Also, a study from Sudan reports that although the use of RDTs seemed to have improved the level of accuracy and trust in the diagnosis, 30% of volunteers did not rely on the negative RDT results when treating fever cases . These mistrusts may be a result of the lack of intensive CHW training and supervision, as well as absence of services for alternative causes of fever at the CHW’s post.
Respondents reported that the majority of CHWs adhered to test results for prescription of drugs to patients. A small portion of CHWs were reported to have been coerced into providing medication to children with a negative RDT or RRT. This is in contrast to a study from Zambia that found adherence to test results to be high with over 99% of patients with a negative RDT result not prescribed an anti-malarial drug .
Bias in recall was a potential problem in this study with caregivers being asked to remember things that happened in the past about an event that may not have been a major event in the home. This was minimized by limiting the recall period to one month for key details, and three months for more general questions about a most recent fever episode in the child. Caregivers responsible for under-fives and not anyone in the household, were interviewed.
Respondents were asked to compare current CHW services with those before introduction of RDTs. It was not established who had utilized CHWs before introduction of RDTs and it is likely that some respondents had never used CHWs in the areas before RDT introduction, but nevertheless responded to the question. This could lead to over or under estimation of the true positive or negative responses.
Interviewer bias is always a possibility in these kinds of studies. This was minimized by using research assistants who had not been involved in the intervention and were blinded to the hypothesis the data collection was based on.
Principal components analysis was used to generate a socio-economic status (SES) index. Fewer variables were used for this study than most often used, for example in the 2006 Uganda Demographic and Health Survey . However, the index does portray the actual picture on the ground in terms of the components used and what is generally understood as what these components represent in terms of SES in the community. While asset-based measures are increasingly being used, there continues to be some debate about their use. These measures are more reflective of longer-run household wealth or living standards, failing to take account of short-run or temporary interruptions, or shocks to the household . Therefore, if the outcome of interest is associated with current resources available to the household (as health services utilization might be), then an index based on assets may not be the appropriate measure . However, under the circumstance, with no other source of information on household income and expenditure in this rural community with a large informal sector, the approach used was considered a reasonable alternative.